O
MELLANRUMMET
Övergångar och psykoterapi • 25 • 2011
TIDSKRIFT OM BARN- OCH UNGDOMSPSYKOTERAPI
Dana Johnson
Psykodramaledare
Stockholm
Psychodrama and the Elderly
The ever-present question – “what is the meaning of life?” – changes radically and reaches
a completely different kind of complexity when we grow old and can no longer move
through the world as we once did. If one is elderly and also dependent on institutionalized
geriatric care the question of the meaning of life becomes even more intrusive.
In the following paper I hope to illustrate how the
group therapy method psychodrama is an effective
form for positively shifting the burdening sense of
loneliness and meaninglessness that many institutionalized elderly endure. I hope to show how a
weekly psychodrama group (sometimes in combination with individual meetings) stimulates, even
at this late stage in life, the development of new
friendships, how it fosters support and acceptance
and allows for complicated feelings, memories and
old issues of resentment to be confronted.
The examples presented here are based on an
ongoing, weekly psychodrama group composed of
members ranging from ages 75-94 years old. The
four year project, funded by the city council of
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southern Stockholm, recently expanded to include
individual therapy in two nursing homes, as well
as, the ongoing afternoon group. Both forms function as an opportunity to examine the difficult issues of aging and illness.
What is psychodrama?
Jacob Levy Moreno (1889-1974), a Viennese psychiatrist, is the founder of psychodrama. He was a
visionary in the field of mental health, and playfully crossed the boundaries between philosophy, sociology, anthropology and psychology. Out of this
inter-disciplinary approach to life developed what
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Dana Johnson: Psychodrama and the Elderly
he described as a ”threefold” therapeutic position:
1.Spontaneity and creativity are the propelling
forces in human nature…
2.Love and mutual sharing are powerful, indispensable working principles in group life…
3.That a superdynamic community based on
these principles can be brought to realization
through new techniques… (Moreno, 1985)
Moreno broke new ground in his conviction
that a dramatic enactment of our intrapsychic
problems is more effective than just talking
”... because the active involvement opens
a corresponding flow of intuitions, images,
feelings and insights that are otherwise distanced and blocked by more passive verbal
modes of interchange.” (Blatner, 2003)
His idea that one of the main goals of therapy
is to help people get in contact with their creativity
by inspiring, with the help of different action techniques, the client’s spontaneity made it possible to
work with feelings, memories and dreams in a completely new way (Blatner, 2003).
As one of the forerunners of the very concept of
group psychotherapy, Moreno early on developed a
complex and innovatory theory for studying group
process called sociometry. Sociometry is a way of
measuring relationships, and tele (the Greek word
for ’at a distance’) is the sociometric measurement
Moreno chose for describing this ”two-way flow of
feelings between people” (Holmes, 1991). Moreno
developed sociometric methods to help groups realize – through the revelation of affinities and disaffinities – their interconnectedness. Psychodrama,
aptly called ”a therapy of relationships” (Karp,
1998), developed out of Moreno’s sociometric
ideas.
The corner stone of psychodrama is Moreno’s
role theory, from which role-playing and role reversal developed. Finding the concepts ’self’ and
’ego’ too limiting, Moreno chose to see the individual as a dynamic interchange of roles and
counter-roles, with the understanding that it is our
valued roles that give us a sense of worth (Blatner
& Cukier, 2007), and often our cultural roles –
the roles we are expected to play – that constrain
a person from fully developing creatively. This is
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25 • 2011
a particularly useful concept when working with
the elderly, most of whom have left behind their
important life roles and well-acquainted ’productive’ positions. The technique of role play allows
one to regain a sense of worth as you review, develop, throw out and even reinvent the many roles
or positions carried throughout a lifetime.
An example from our group
It was obvious from the start that two of the female
members – Greta and Eva – seemed to have difficulty connecting. Over the weeks, with the help
of different warm-up exercises that explored the
group’s commonalities, differences and themes, it
became clear that these two had few points of reference or experiences in common. Although they
did not seem uncomfortable together, they seldom
directed comments to one another.
Eva is close to Siri, another woman in the
group. They share a deeper connection, both having been mothers and married. Greta, on the other
hand, has always lived alone. Eva and Siri have also
been the two members most open and forthright
about their desire to die. Greta (the eldest of the
three) asserts during these admissions her strong
desire to live.
Into our fifth month of meeting, Eva, encouraged by another member’s story of losing his
mother when he was ten, bravely shared her experience of having lost a parent early on in life. In
the role of her mother, she spoke (to her six year
old self), explained why she had suddenly one day
disappeared, how she had been taken to a hospital
and never gotten better. The group listened attentively. Greta had previously not offered much information about herself, and tended to recycle the
same pictures over and over again. She would often
say: ”Nothing happens. Everything is always the
same.” But this time, inspired by Eva, she continued the thread and told the story of losing a close
relative who, she revealed, had been ”like a child
to me”.
We were starting to run out of time, and still
needed to allow for a final sharing. Taking a large
red balloon I encouraged the group to cast it to one
another, and send a comment on the way. As the
balloon floated from arms to laps, admissions were
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Dana Johnson: Psychodrama and the Elderly
sent around the circle:
• You and I have the same story.
• I like speaking with you more than anyone
I’ve ever known.
• This group is important to me.
When the balloon landed for the third time in
Eva’s lap she paused briefly and then turning to
Greta cast it lightly and said, ”I would miss you
if you weren’t in this group”. The look on Greta’s
face lit up the room.
From the outside, a simple gesture, but in the
context of the ambivalence that had existed between Eva and Greta, it was a significant shift. The
atmosphere became more open after this session
and at the same time more protective, there was
less resistance to try something new and also more
healthy disagreement amongst the members.
Another example
Siri arrived looking both troubled and resigned.
During the ”round” (often, the beginning of a session when each member is given uninterrupted
time to share thoughts from the previous meeting
or anything meaningful from the week that has
past) Siri admitted that she no longer felt safe at
the nursing home. I tried to encourage her to work
with the worry and fear she expressed, but was met
with a sturdy resistance. ”Nothing can be changed
now. It’s too late to change”. So, the group was
asked to imagine: If you could live your whole life
again, what would you change? Siri, with unusual
force, was the first to reply: ”I would never have
married my husband!”. The spontaneous directness of her admission inspired other members:
• I would live a less careful life.
• I would change something now…the
boats to Finland. For me to afford the
journey, I have to share a room, and I want
to sleep on my own. I need to be alone at
night.
• I would like to experience more of my time
during the war. I travelled so much and saw
the world. And I would dance more.
• The 20 years with my last husband…those
years again. I received so much love.
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The session continued with different role reversals: Siri in the role of her husband, Greta in
the role of her ”wilder” self, and Per in the role of
his former wife whom he acknowledged he regretted divorcing, but now had the opportunity to say
what he had not dared to admit before ”because
I was too proud”. In our final sharing, Siri came
full circle. ”There were things I liked about him. In
fact, we had some good times too”, she pondered.
The way in which psychodrama techniques,
like role reversal, can lead the protagonist – the
lead person in the drama – to an empathic understanding of herself, a former role or another person
is one of its most therapeutic effects. It can often
help the protagonist to profoundly shift perspective and thereby see a situation or relationship that
had otherwise been hidden or seemed impossible,
in a completely new light.
Three main parts
A traditional psychodrama session involves three
main parts:
The warm-up uses exercises to help the group
(including the leader, also called ’the director’) get
in touch with their spontaneity. As the first section of a psychodrama, it should support group interaction and through the promotion of play, help
lessen any sources of anxiety.
The enactment or the action is when a stage is
set allowing the protagonist to work with different issues, practice new roles, see oneself and other
significant people from different perspectives and
overall gain insight. In the safety of the psychodrama stage everything is allowed. In other words, the
stage should provide the protagonist with a sense
of freedom, ”…freedom from unbearable stress
and freedom for experience and expression.”
Sharing is the final part of a psychodrama or the
conclusion of the action. It is the time for the protagonist to sit back and take in reflections from the
group members who are instructed to share from
feelings that have been awakened during the drama or from insights gained from the auxiliary roles
(helper roles) that they have played. Criticism,
advice and intellectual analysis are avoided, since
this is a time to support the protagonist who can
be feeling vulnerable. One of the greatest values of
the sharing stage is the connection group members
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Dana Johnson: Psychodrama and the Elderly
make as they realize they are not alone, that others
feel as they do (Sternberg & Garcia, 2000).
When working with the elderly, a full classical psychodrama session is rarely possible because
of physical disabilities. Afflictions such as pending blindness, hearing impairment and arthritis,
in combination with more critical illnesses such
as cancer, MS, autoimmune disorders, Parkinsons
and heart disease – are complaints many elderly
stoically manage.
But these limitations do not necessarily inhibit
the method from being less effective. It is, in fact,
the subtle tools of psychodrama that are often
most useful, and this has clearly been the case with
our group.
1.To experience oneself as a significant part of a
group’s history, is a curative experience. Simple rituals like – the consistent weekly time,
the value given to attendance, the knowledge
that nothing is too odd to share and that all
that is shared remains confidential – enhance
the sense of belonging to a meaningful process. The group serves as a container for rituals that ”mark off time to allow for an orderly
recognition of the passing of life” and as ”an
opportunity for the members to reenact their
bonding to a shared social enterprise” (Sandel
& Johnson, 1987).
2.When the major question posed by the elderly
is: “what is the meaning of life at this last stage
of life?” – participation in a weekly therapy
group that promotes the experience of meaningful connection can be transformative. The
group begins to replace the sense of loss of family and old friends.
3.Through contact with other members life stories – their difficulties and joys! – the awareness
that ”You and I have the same story” relieves
the feeling of being all alone. As well, we get to
know ourselves inspired by others, and become
creative instruments to another’s interpersonal
learning.
4.The seemingly simple act of listening is, on its
own, therapeutic. This is particularly relevant
for the institutionalized elderly person who
is used to being passed by or spoken to in the
third person, who’s days are filled with waiting for her most basic needs to be met. To be
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25 • 2011
listened to, without the passing of judgment
or suggestions to solve the problem helps the
elderly person perceive himself as significant
again. ”Our intimacy with patients is based
predominantly on listening to what they tell
us, and our trustworthiness toward them is
demonstrated in the seriousness and duty with
which we listen to what they entrust us with”
(Charon, 2006). When the engagement feels
authentic all participants (therapist and client)
are transformed.
5.Often, the same story or issue comes up, indicating that it is bothersome and needs attention. Arvid’s “pills” (see below) is a good
example. In the re-telling and with the aid of
simple psychodramatic techniques like role
reversal, the elderly client works to reframe a
memory so that the meaning changes and new
viewpoints are offered. The repetition acts as
a catharsis.
6.Some issues are not easy to discuss, for many
reasons. A secret shuffled under the rug or
locked safely away for years may seem forgotten, but can fester deep in the psyche and
cause an older person anxiety. Psychodrama
techniques are effective in helping to creatively
work with resistance surrounding ”unfinished
business”. Even simple movement exercises
can be a first step in helping a person open up,
as memories are triggered through interaction
(Sacks, 1995).
However subtle or obvious these points may
seem they are powerful tools for working with the
frail elderly person, who although often physically
limited, is still (if not hindered by a loss of brain
function) emotionally vital.
Over-medicalization
The over-medicalization of the elderly – especially
in nursing homes, where illness in old age is taken
for granted and medicine rather than counseling is
often chosen as the best ”solution” – is a common
issue the members want to discuss.
Arvid shared, at our very first meeting, his misgivings about the amount of medication he was
regularly prescribed – 30 pills a day. Time after
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Dana Johnson: Psychodrama and the Elderly
time he returned to this subject, because he could
not help but feel that the extreme tiredness he experienced (he was sleeping 14-15 hours a day), was
a result of the combination and amount of medication he was taking. In response, group members
shared information about the abundance of pills
they were prescribed, comparing both their positive and negative experiences. One group member
in particular began encouraging Arvid to confront
his doctor and do something about his situation.
Following a particularly intense discussion
about their medication I asked the group to discard all of their pills into the ”magic garbage can”.
Then, using different sized and coloured balls and
balloons, the center of our circle was playfully filled
up with their necessary pills. Each member was
asked to choose from this colorful pile the pill they
needed most just now.
• I need this against the coming November
darkness (a small rainbow colored ball).
• I choose this white one, because it’s the
only one I really need for my epilepsy,
which scares me.
• This blue one. It’s freedom.
Arvid role reversed with his freedom pill,
and then was guided to set a scene where he felt
most free. He described a summer home. Different colored materials were used to symbolize his
surroundings (the mountains, a nearby village, the
bordering lake), accompanied by simple role reversals. Sitting alone by his cabin, looking out over
the water he seemed more content, but something
was still missing. He wanted to bring the group
with him.
Some weeks later, Arvid surprised us when he
rolled in with a new found energy. The lethargy
and fogginess which he had previously shown was
gone, and with vigor he told us about confronting
his doctor and insisting that he eliminate some of
the medication. After reviewing the long list of
pills, his doctor agreed that the only ones that were
really necessary were aspirin and his Parkinsons
medication. Arvid, who before had sat hunched
and listless, now tapped his feet impatiently. The
group listened to the account of his meeting with
his doctor with unusual attention, and when he
was finished applauded his nerve. I am convinced
that it was not just the reduced amount of medica-
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tion that invigorated Arvid, but also the support he
felt from the group and the revived role of himself
as a person in control of his life.
The core theme
One morning the coordinator for daily activities at
the nursing home asked me for a description and
name of our group, to include in an upcoming information letter. We began our next meeting with
a short discussion about what to call ourselves. Per
quickly responded with a vote for ”The Psychodrama Group!”, but was soon over-ridden, and a
general discussion and questioning about what we
actually do followed.
• At first I thought it was like religion … it’s
spiritual.
• I’d say, interesting.
• We talk about a lot of things … there’s
room for everything.
• It’s about our feelings … We can speak
about things we can’t tell our children.
• Death … it’s difficult to speak to others
about death … they don’t really want to
hear about that.
Then one member exclaimed, ”Let’s call our
group ’Friends to the End’, like when we were
children” adding, ”…but now we really are at the
end!”.
Although death is the underlying theme in an
elderly group, it is not necessarily a topic that pulls
a group down. When confronted, it can instead
change the way we feel about life even when we are
at the end of our lives. The difficulty is when there
exists no forum for sharing the intensity of feelings
that accompany old age. If one lives in an institutionalized setting, surrounded by daily reminders
of timelessness, immobility and the real presence
of death, the need for a therapeutic outlet is even
more acute.
Most of us live our lives fearful of death. The
dread is always there, at the edge of things, pervading even the best of times. The idea of death as a
positive aspect of life, however, is a less accepted
notion. In his seminal work Existential Psychotherapy (1980), Irwin Yalom looks to existential
philosophical thought to explore the potential ef-
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Dana Johnson: Psychodrama and the Elderly
fectiveness of a psychotherapeutic approach based
on death awareness, particularly the ideas of the
German philosopher Martin Heidegger who, in
1926, began to explore his belief that our understanding of death heightens our experience of life.
Heidegger came to the conclusion that there
were two ways of existing: (1) a state of forgetfulness of being or (2) a state of mindfulness of being.
”When one lives in a state of forgetfulness
of being, one lives in the world of things
and immerses oneself in the everyday diversions of life. One surrenders oneself to
the everyday world, to a concern about the
way things are ... In the other state, the
state of mindfulness of being, one marvels
not about the way things are but that they
are. To exist in this mode means to be continuously aware of being ... not only mindful of the fragility of being but mindful too
of one’s responsibility for one’s own being.
Since it is only in this ontological mode
that one is in touch with one’s self-creation,
it is only here that one can grasp the power
to change oneself.” (Yalom, 1980)
Heidegger described the first state – forgetfulness of being – as an ”inauthentic” way of being,
and the second state – mindfulness of being – as
a way of existing authentically: one ”faces” rather
than ”flees”. In order to reach the second more
heightened level, he believed one needed to be
triggered by ”urgent experiences”, and of all the
urgent experiences to choose from, death is the
most receptive state because ”Death opens up the
question of Being” (Heidegger, 2001). Older, aging people exist in this most receptive state since
the confrontation with their own death lies so close
at hand. I believe that if we offer the elderly person a chance to explore an ”authentic realization
that it is possible not-to-be” what will follow is the
possibility of regaining the feeling of ”being-ableto-be”.
A final example from our group
We had not met since the summer holidays. As always, we began with a ’round’. Siri was the last in
our circle. With a faraway look she stated, ”Noth-
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ing pulls me anymore. There’s no meaning left in
life.” The group listened thoughtfully.
Hoping to gather some information about
what people would like to work with during the
coming weeks I had prepared a warm-up, but
before I had time to begin Greta blurted out, ”I
don’t feel that way at all. I want to live!” Per continued spontaneously: ”There’s not enough time.
I want to write down my life story and there’s not
enough time!” Ingrid, agitated, expressed her frustration at not having a companion to walk with,
and ”one who can walk as quickly as I can!”. Eva
then snapped sternly, ”Death. I don’t want to live
anymore! That’s my theme.” She went on to clarify that if she were struck by a heart attack in the
night, she’d consider herself lucky.
I guided the group to close their eyes and focus on something that could ”pull them, just now”.
Eva, calmer, described how, if she were healthy and
could walk (she is wheelchair-bound), she would
travel somewhere in the world to help people in
need. The group responded that she was needed
right here in our group. Eva returned a look of disbelief, with a half smile
The next session we continued exploring
themes on paper. Eva drew a child figure at the beginning of a path. At the end of the path was a pile
of ash. She called it ”Life and Death”. I asked her
about the space between the child and the ashes.
She said it was the sun, and chose a warm redcolored material which she bunched up into a ball
and held close to her chest. ”It feels good”, she said.
We continued with simple role reversals where
each member of the group was given the opportunity to work with the content of their drawing.
Everyone was gathered in the room for our
next session except for Siri. As we were just about
to begin, she arrived with the help of a staff member, highly agitated, having gotten lost (something
that had never happened before) ”in the cellar,
two times!” Eva, who had been ready to begin our
ritual round, turned to Siri and said lovingly, ”You
should start”. Siri shared her despair and anger. ”I
don’t want to live anymore!” she confessed. The
group listened and then responded caringly. Per
turned to her first: ”But it wouldn’t be the same
here without you”. Eva continued, ”Siri, you’re
very important to us here. I would miss your
lovely blue eyes”. Arvid, a man of few sentimental
words, caught Siri’s attention and nodded sternly
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Dana Johnson: Psychodrama and the Elderly
in agreement. Siri’s whole demeanor changed. The
simple responses of care and love, the fact that she
had been allowed to express her darkness without
being interrupted or met with inappropriate responses, shifted the weight and lightened the load
she had been carrying.
Final thoughts
The question of whether or not the group therapy
method psychodrama can respond to and meet
the institutionalized elderly person’s longing for
meaning is for me, partly rhetorical. During the
past four years I have seen how effective it can be.
At the same time, from a research and experiential
standpoint it is necessary to maintain a problemoriented approach: the psychodramatic method
must continuously be transformed because of the
various physical barriers and personal histories,
and persistently questioned as to what are the consequences of therapeutic quality in the long run?
Today’s Swedish elderly care system offers few
opportunities for group or private therapeutic exchanges. Although there is a general growing understanding and awareness of the importance of
highlighting the psychosocial needs of the institutionalized elderly, the situation in most nursing
homes is characterized by shortages, uncertainty
and change. Even in the best of nursing homes,
with a committed staff and welcome atmosphere,
the elderly resident must quickly learn to accept
days suspended in time and marked by a complete
dependency on others – a position that requires
a particular kind of stoicism, difficult to comprehend. After four years as psychodrama leader at
two of Stockholm’s retirement homes, I can safely
say that the need for meaningful therapeutic exchange, for the elderly, is bewildering.
To survive the timelessness that permeates the
atmosphere of most nursing homes, we need to offer activities that stimulate the sense of being rather
than having been. We cannot change the fact of becoming old and often sickly, but we can change the
experience of it by providing outlets that challenge
one to function and feel better, and that respond to
the older person’s need for contact that is intimate,
deep and genuine. As study after study confirms,
loneliness is detrimental to our health: people
need people.
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25 • 2011
Harvard University conducted what is considered the longest and most complete study of adult
development in the world, when a broad spectrum
of 824 individuals were followed from their teenage
years throughout their entire life (Vaillant, 2003).
In a way, they concluded with a similar finding:
• It is not the bad things that happen to us
that doom us; it is the good people who
happen to us at any age that facilitate enjoyable old age.
• Healing relationships are facilitated by a capacity for gratitude, for forgiveness, and for
taking people inside.
As an instrument for self-knowledge and communion, a weekly psychodrama group can help one
make sense of what it means to be human through
the revelation of our commonalities and thereupon, the nourishing bonds that hold us all together.
It can help transform the sense of inertia and fear
of being alone – the two major complaints of the
elderly – into energy and spirit.
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References
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Johnson, D., Smith, A. and James, M. N.J.:
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Blatner, A. & Cukier, R. (2007). In Psychodrama: Advances in Theory and Practice. London:
Routledge.
Charon, R. (2006). Narrative Medicine. Oxford
University Press.
Heidegger, M. (2001). Heidegger: A Beginner’s
Guide. London: Hodder & Stoughton.
Holmes, P. (1991). In Psychodrama: Inspiration and
Technique. Eds. Holmes, P. & Karp. M. London: Routledge.
Karp, M. (1998). In The Handbook of Psychodrama.
Eds. Karp, M., Holmes, P., Bradshaw Tauvon,
K. London: Routledge.
Moreno, J.L. (1946). Psychodrama, First Volume.
NY: Beacon House.
Moreno, J.L. (1985). The Autobiography of J.L.
Moreno, M.D. (Abridged). Moreno Archives,
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Copyright. Alla rättigheter förbehållna. Mångfaldigandet av innehållet, annat än för privat bruk, är enligt lag om upphovsrätt (1960:729) förbjudet utan medgivande av redaktionen.
Ansvarig utgivare: Kristofer Wikstad, Föreningen för barn- och ungdomspsykoterapeuter.
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Dana Johnson: Psychodrama and the Elderly
25 • 2011
Harvard University.
Sacks, H. (1995). Lectures on Conversations. Oxford:
Blackwell.
Sandel, S. & Johnson, D. (1987). Waiting at the
Gate: Creativity and Hope in the Nursing Home.
London: Taylor & Frances Group, Haworth
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Who’s in Your Shoes? S:t Barbara: Praeger.
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Yalom, I. (1980). Existential Psychotherapy. N.Y.: Basic Books.
Keywords: psychodrama, psykodrama, existential psychotherapy, psychology of ageing, reminiscence, äldreboende, nursing homes.
Abstract: This paper uses examples from an ongoing weekly psychodrama group, composed of
members ranging from ages 75-94 years old, to explore how the group therapy method psychodrama
can respond to and meet the institutionalised elderly person’s longing for a meaning to be. The case
examples are combined with a concise description
of the method and it’s possible application to an
elderly group.
Dana Johnson är psykodramaledare och arbetar
med grupper inom åldringsvården vid Södermalms
stadsdelsförvaltning i Stockholm stad. I artikeln
beskriver hon hur psykodramagrupper med äldre
människor kan hjälpa dem i den övergång som
åldrandet och närmandet av livets senare skede
innefattar. (Alla namn i artikeln är fingerade och
tillstånd har givits till publikation).
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Copyright. Alla rättigheter förbehållna. Mångfaldigandet av innehållet, annat än för privat bruk, är enligt lag om upphovsrätt (1960:729) förbjudet utan medgivande av redaktionen.
Ansvarig utgivare: Kristofer Wikstad, Föreningen för barn- och ungdomspsykoterapeuter.
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